Hard questions about the distribution of health care resources are confronting medical ethicists as pandemic influenza quietly advances. But experts say the same difficult issues should be put to ordinary Canadians who are staring at a virus that could mutate into something very ugly.
Will most be willing to let natives - who have proved especially susceptible to the H1N1 virus - go to the front of the queue for vaccines if the pandemic influenza mutates into something far more deadly this fall?
Should scarce resources, including ventilators, be allocated on a first-come, first-serve basis? Or should they go to the person who is sickest? Or to the person who has the best chance for recovery?
And if health-care workers get priority for inoculation and treatment, does that include those who make the vaccine? What about emergency personnel such as firefighters and police? Or transit workers? Or the military?
These are the issues that federal and provincial health officials are debating as they craft guidelines to be used in the event of a pandemic surge.
Peter Singer, a bioethicist at the University of Toronto, says it is important the Public Health Agency of Canada sets priorities before what some doctors say could be the first triage of its kind since the Second World War.
But Dr. Singer said the debate should be broadened beyond health experts.
"There is now about six weeks between now and when a second wave might start. A great use of that six weeks would be to deeply engage the public on how they see the priorities being proposed by experts groups and government groups."
Dr. Singer urges public health officials to turn to social media such as Facebook and reader comments on newspaper stories to gauge how the public believes flu-fighting resources should be dispensed.
The problems that confront a society fighting a pandemic are, in large part, the type that money cannot solve. A vaccine can't be created and distributed faster than science will allow. And there is only so much space in critical-care units with the infrastructure required to run a ventilator.
The World Health Organization has stated that health workers should be first in line for vaccines. After that, it is up to countries to draw their own guidelines. The Public Health Agency of Canada said last week that those guidelines will be finalized close to the time that the vaccine is ready for distribution, likely in early November.
And the allocation of treatment provided for the critically ill will require a completely different set of priorities. It will be up to each province or territory - with guidance from the federal government - to develop its own criteria for determining which patients will get preferred access.
Even when the guidelines are drawn, it will not be easy to tell some groups of people they will have to wait for vaccines. And it will not be easy to make life-and-death decisions in hospital wards about the distribution of health-care resources.
Gerald Evans, chief of the division of infectious diseases at Kingston General Hospital, said the guidelines will be useful in terms of developing a general priority list.
But "I think it is going to be much more difficult, as somebody who sees real patients and takes care of real patients, when it gets down to the nitty gritty of two people who are virtually equivalent in terms of what the guidelines might say," he said.
"That's where it becomes very, very hard. And that's where the guidelines aren't useful. And that's where clinical judgment comes into play."
But the guidelines will at least provide a starting point.
Ross Upshur, director of the Joint Centre for Bioethics at the University of Toronto, said there are certain criteria that should never be considered when determining who will get access to health care. These include willingness to pay and a wide range of social factors.
Age alone, for instance, should not decide who gets a ventilator, Dr. Upshur said. Nor should gender, race or religion. "Those are not on the table."
But how will doctors decide which of two otherwise healthy young adults should be given treatment if there is not enough to go around?
"You could look at ways of treating people equally. The two best ways of doing that are using a lottery or using a first-come-first-serve principle," Dr. Upshur said.
Or, doctors could make decisions based on established criteria.
"You could look to favouring people who are worst off. That would be giving it to the 'rule of rescue' - giving it to the sickest first."
But an argument can be made for doing the opposite - giving treatment to those who have the greatest potential to benefit, he said.
In New York, for instance, a pandemic working group recently developed clinical guidelines that "propose both withholding and withdrawing ventilators from patients with the highest probability of mortality to benefit patients with the highest likelihood of survival."
Or you could reward social usefulness, Dr. Upshur said. "The reciprocity argument is often used for veterans, they served their country therefore they should have first call to it."
All of these are simple principles, Dr. Upshur said, none of which on their own is sufficient or complete enough to be the primary deciding factor for the distribution of scarce health resources.
"What you have to do is find ways to integrate, weigh and balance these in relation to each other," he said. "That's why it starts to become morally complex, when you start to weigh and balance different priority mechanisms against the other."
In 2005, the Joint Centre for Bioethics created one of the leading documents on ethical considerations in pandemic planning that is being used by governments and health officials around the world.
It provides thoughts for setting guidelines and argues that the public must become involved.
Members of the public are the stakeholders in this exercise, Dr. Upshur said.
"They fund the health-care system through taxation." And health officials need to "get a finger on the [public]pulse of what's considered to be appropriate or inappropriate on priority lists."